Orthopaedics & Traumatology: Surgery & Research (2013) 99, 631—634

Available online at

www.sciencedirect.com

CASE REPORT

Incidental discovery of an undisplacedceramic liner fracture at total hiparthroplasty revision for squeaking

C. Dacheuxa,b,∗, D. Bocqueta,b, H. Migauda,b, J. Girarda,b,c

a Service d’orthopédie C, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille,59037 Lille cedex, Franceb Université Lille-Nord de France, 59000 Lille, Francec Département de médecine sportive, université de Lille, 59045 Lille cedex, France

Accepted: 13 May 2013

KEYWORDSSqueaking;Ceramic failure;Total hip arthroplasty

Summary Squeaking has been reported after ceramic-on-ceramic total hip arthroplasty (THA),but its pathomechanics is not fully understood. Impaired lubrication is suspected to be the mainreason. The management of patients impacted by this phenomenon is not well defined and, asit is not considered to be cause for alarm, revision is not strongly recommended. Here, wedescribe a ceramic insert fracture discovered during revision surgery performed to correctsevere squeaking. Preoperative investigation (plain X-rays, ultrasound and computed tomogra-phy) did not reveal ceramic fracture or definite component malposition. To date, there are

no other published cases of incidental discovery of a bearing component fracture during revi-sion of ceramic-on-ceramic hip replacement due to squeaking. We believe that squeaking isnot a trivial phenomenon and recommend careful management of patients suffering with thissymptom.© 2013 Elsevier Masson SAS. All rights reserved.

∗ Corresponding author. Service d’orthopédie C, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, 2,avenue Oscar-Lambret, 59037 Lille cedex, France.Tel.: +33 03 20 44 68 28; fax: +33 03 20 44 66 07.

E-mail address: charles.dacheux@yahoo.fr (C. Dacheux).

I

Ctttof[r

1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights rehttp://dx.doi.org/10.1016/j.otsr.2013.05.001

ntroduction

eramic-on-ceramic coupling (COC) is known for its resis-ance to wear and its bioinertia [1]. In contrast to otherypes of bearings, no metal ions are released, and peripros-hetic osteolysis is rare [2]. However, the main drawbacks

f these bearings are cup fixation and the risk of componentracture [3,4]. Ceramic fractures may occur spontaneously5,6] and may be diagnosed during revision for unrelatedeasons [7]. Recently, squeaking was reported with COC at

served.

6 C. Dacheux et al.

at[sucair

tdt

C

A1at3iNdmm

catentdapdsab

Fpmo

Figure 2 CT-scan showing 22◦ cup anteversion and 9◦ forthe stem. Liner breakage and ceramic fragments could not bedetected on CT-scan.

Figure 3 At surgery, the cup liner was found to be broken but

32

frequency ranging from 0.7 to 20.9% [8—10]. This symp-om has multifactorial etiologies. Cup [9] and stem design11,12] has been incriminated, with the lubrication systemuspected of being the main causative factor [13]. The nat-ral outcome of squeaking is not alarming, as no relatederamic component fractures occur [14]. Although someuthors consider squeaking to be a benign symptom [15,16],t can become socially and psychologically unacceptable,equiring revision surgery [9,15,16].

We report the revision of disturbing and persistent COCotal hip arthroplasty (THA) squeaking that allowed theiscovery of an asymptomatic ceramic acetabular liner frac-ure.

ase report

43-year-old man, with a body mass index of 27.8 (85 kg,.85 m), was referred to our institution for persistentnd disturbing squeaking from his right COC hip. Owingo secondary osteoarthritis, his hip had been replaced

years earlier through an antero-lateral approach in anothernstitution. Cementless COC components (Amplitude SAS,eyron, France) with 56-mm cup diameter and 36-mm headiameter were implanted. The bearing components wereade of Biolox ForteTM Alumina (Ceramtec, Plochingen, Ger-any).Noise started spontaneously 9 months after the index pro-

edure. The patient complained of squeaking sounds as soons he started walking (Video). Rated as grade 4 accordingo the classification of William et al. [17], it occurred atvery step or change of position. Physical examination wasormal and could not reproduce any groin pain. X-rays iden-ified excessive cup inclination (57◦) (Fig. 1). Ultrasoundetected limited intra-articular effusion but no debris. Stemnd cup anteversions were 9◦ and 22◦, respectively, on com-uted tomography (CT)-scan (Fig. 2). X-rays and CT-scans

iscerned no breakage of ceramic components. Revisionurgery was scheduled considering the severity of squeakingnd cup inclination. At surgery, the cup liner was found toe broken, in three large fragments (Fig. 3). We replaced

igure 1 Antero-posterior (AP) and lateral radiographs ofatient. The AP view shows excessive cup inclination (57◦) thatay have favored ceramic liner breakage. There is no evidence

f ceramic breakage.

ne

tpawftw

D

Tit[hbcsphT

ot displaced. Three large fragments were observed (postop-rative view on retrieval is shown in the insert).

he cup and ceramic head by a new 36-mm ceramic-on-olyethylene bearing. No periprosthetic osteolysis was seen,nd synovectomy was not required since no ceramic debrisas encountered. The postoperative period was unevent-

ul, and the squeaking disappeared. At 3 years follow-up,he functional and radiological outcomes were satisfactoryithout signs of osteolysis.

iscussion

he delayed onset of squeaking in the present case wasn accordance with previous studies, which reported thathis symptom occurs within the first postoperative year8—10]. To the best of our knowledge, squeaking of bulk COCip replacement with unrecognized fracture of a ceramicearing insert has never been described. Only studies oferamic inserts with polyethylene sandwich have mentioned

uch complications [3], and the brittleness of these com-onents is well established [18,19]. Finally, no consensusas emerged concerning the management of squeaking COCHA: surgeons skilled in ceramic bearings do not recommend

eaki

np

torolaoge

ctIn

D

N

M

Z

Z

A

Sfj

R

Ceramic liner fracture discovered during revision of THA squ

systematic revision unless radiographic abnormalities havebecome apparent [20]. Schroder et al. [21] noted squeakingin 1.9% of alumina COC bearings, but did not suggest system-atic revision. Our understanding of squeaking phenomenonis deficient: suboptimal component design [12], insufficientlubrication [13], edge-loading wear or micro-separation [22]and inadequate component alignment [8] have been incrimi-nated. In fact, squeaking is considered by many authors to bea minor complication that does not warrant systematic revi-sion [16]. The current study disclosed that squeaking mightreveal ceramic component fracture requiring revision.

Our investigation has some limitations. First, we couldnot ascertain a direct relationship between squeaking andceramic liner breakage, and we were unable to preciselydetermine the date of this complication. However, the com-ponents deployed in the present study were not reportedto be associated with a high frequency of squeaking orceramic breakage [23]. Chevillotte et al. [23] found 5% casesof squeaking among 100 COC THAs with the same designbut observed no liner breakage. Second, another team hasalready reported previously unrecognized ceramic compo-nent fracture that was diagnosed at revision for infection[7]. For comparison with this earlier study, we undertookan extensive preoperative investigation (ultrasound and CT-scan) but were unable to detect liner breakage. Third,breakage of ceramic components occurs with low frequency(0.3%) [4] and requires rapid revision with extensive syn-ovectomy in case of disseminated ceramic debris [6]. We didnot perform extensive synovectomy despite ceramic compo-nent breakage. In our opinion, extensive synovectomy wasnot justified because ceramic fragments were not displaced.However, this observation is debatable since the existenceof ceramic microparticles cannot be discounted. Fourth,we did not implant a ceramic cup in case of ceramic linerbreakage, since the original purpose of revision was to pre-vent recurrence of squeaking and ceramic breakage. Usinga polyethylene insert is debatable when ceramic breakageoccurs, but it can simplify revision, embedding potentialceramic debris in polyethylene and being less aggressive onbearing components than hard bearings [6]. The absence ofsynovectomy and use of ceramic-polyethylene bearing canbe discussed, but 3-year follow-up did not reveal osteolysisor abnormal polyethylene wear.

Containment of the broken liner in its metallic shellcould explain the absence of radiographic signs and thedelayed diagnosis but jeopardized lubrication, thus enhanc-ing squeaking [13]. Excessive inclination (57◦) may havecontributed to disruption of lubrication and may havefavored ceramic liner breakage. However, employing thesame prosthetic design with 28-mm bearing and similarthickness of ceramic liner, Chevillotte et al. [23] deter-mined that high inclination was not associated with ceramicliner breakage. The 36-mm head with 56-mm metal backand internal diameter of 44 mm may be another factor thatcould explain the fracture, since ceramic thickness was only4 mm at the equatorial aspect. Cogan et al. [20] emphasizedthat ceramic insert diameter had no influence on squeaking.Traina et al. [24] suggested that malorientation of compo-

nents, much more than ceramic thickness, was the maincause of ceramic breakage, as in the current study (highinclination). Traina et al. [24] reported high occurrence ofsqueaking in cases of ceramic breakage that reinforced the

ng 633

eed for complete investigation of noisy hips, as in theresent work.

The current case report highlights that basic investiga-ions may be insufficient to diagnose undisplaced fracturesf ceramic liners, particularly if no small particles areeleased into the joint. Arthroscopy may be an interestingption, but is limited to date to the resection of grosslyoose pieces of hip prostheses [25]. In the present case, hiprthroscopy could be indicated to complete investigationsf squeaking hips, after eliminating other possible etiolo-ies, such as component malorientation and impingement,specially if squeaking is frequent or constant.

Our case report indicates that squeaking may revealeramic breakage, which is why squeaking requires addi-ional assessments, if conventional radiography is normal.n these cases, hip arthroscopy may be helpful to detecton-displaced liner breakage.

isclosure of interest

o direct conflicts related to this work.C.D. Conflict of interest: none.D.B. Occasional research and education consultant for

edacta.H.M. Occasional research and education consultant for

immer and Tornier; and receives royalties from Tornier.J.G. Occasional research and education consultant for

immer, Wright and Smith and Nephew.

ppendix A. Supplementary data

upplementary data associated with this article can beound, in the online version, at http://dx.doi.org/10.1016/.otsr.2013.05.001.

eferences

[1] Yoo JJ, Kim YM, Yoon KH, Song WS, Kim HJ. Alumina-on aluminatotal hip arthroplasty. A five-year minimum follow-up study. JBone Joint Surg Am 2005;87:530—5.

[2] Hamadouche M, Boutin P, Daussange J, Bolander ME, Sedel L.Alumina-on-alumina total hip arthroplasty: a minimum 18.5-year follow-up study. J Bone Joint Surg Am 2002;84:69—77.

[3] Poggie RA, Turgeon TR, Coutts RD. Failure analysis of aceramic bearing acetabular component. J Bone Joint Surg Am2007;89:367—75.

[4] Hannouche D, Nich C, Bizot P, Meunier A, Nizard R, Sedel L.Fractures of ceramic bearing: history and present status. ClinOrthop Relat Res 2003;417:19—26.

[5] Suzuki K, Matsubara M, Morita S, Muneta T, Shinomiya K. Frac-ture of a ceramic acetabular insert after ceramic-on-ceramicTHA — a case report. Acta Orthop Scand 2003;74:101—3.

[6] Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H,Goutallier D. Revision total hip arthroplasty performed afterfracture of a ceramic femoral head. A multicenter survivorshipstudy. J Bone Joint Surg Am 2003;85:825—30.

[7] Sariali E, Stewart T, Mamoudy P, Jin Z, Fisher J. Undectectedfracture of an alumina ceramic on ceramic hip prothesis. J

Arthroplasty 2010;25:658.

[8] Walter WL, O’Toole GC, Walter WK, Ellis A, Zicat BA. Squeak-ing in ceramic-on-ceramic hips: the importance of acetabularcomponent orientation. J Arthroplasty 2007;22:496—503.

6

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

34

[9] Keurentjes JC, Kuipers RM, Wever DJ, Schreurs BW. High inci-dence of squeaking in THAs with alumina ceramic-on-ceramicbearings. Clin Orthop Relat Res 2008;466:1438—43.

10] Mesko JW, D’Antonio JA, Capello WN, Bierbaum BE, NaughtonM. Ceramic-on-ceramic hip outcome at a 5- to 10-yearinterval: has it lived up to its expectations? J Arthroplasty2011;26:172—7.

11] Restrepo C, Post Z, Kai B, Hozack WJ. The effect of stemdesign on the incidence of squeaking in ceramic on ceramicbearing total hip arthroplasty. J Bone Joint Surg Am 2010;92:550—7.

12] Parvizi J, Adeli B, Wong JC, Restrepo C, Rothman RH. A squeakyreputation: the problem may be design-dependent. Clin OrthopRelat Res 2011;469:1598—605.

13] Chevillotte C, Trousdale RT, Chen Q, Guyen O, An KN. The 2009Frank Stinchfield Award: hip squeaking: a biomechanical studyof ceramic-on-ceramic bearing surfaces. Clin Orthop Relat Res2010;468:345—50.

14] Restrepo C, Matar WY, Parvizi J, Rothman RH, Hozack WJ. Natu-ral history of squeaking after total hip arthroplasty. Clin OrthopRelat Res 2010;468:2340—5.

15] Matar WY, Respetro C, Parvizi J, Kurtz SM, Hozack WJ. Revi-sion hip arthroplasty for ceramic-on-ceramic squeaking hipsdoes not compromise the results. J Arthroplasty 2010;25:

81—6.

16] Mai K, Verioti C, Ezzet KA, Copp SN, Walker RH, Colwell JrCW. Incidence of squeaking after ceramic-on-ceramic total hiparthroplasty. Clin Orthop Relat Res 2010;468:413—7.

[

C. Dacheux et al.

17] William N, Capello W, D’Antonio JA, Feinberg JR, ManleyMT, Naughton M. Ceramic-on-ceramic total hip arthroplasty:update. J Arthroplasty 2008;23:39—43.

18] Hasegawa M, Sudo A, Uchida A. Alumina ceramic-on-ceramictotal hip replacement with a layered acetabular component. JBone Joint Surg Br 2006;88:877—82.

19] Park YO, Hwang SK, Choy WS, Kim YS, Moon YM, Lim SJ. Ceramicfailure after total hip arthroplasty with an alumina-on-aluminabearing. J Bone Joint Surg Am 2006;88:780—7.

20] Cogan A, Nizard R, Sedel L. Occurrence of noise in alumina-on-alumina total hip arthroplasty. A survey on 284 consecutivehips. Orthop Traumatol Surg Res 2011;97:206—10.

21] Schroder D, Bornstein L, Bostrom MP, Nestor BJ, PadgettDE, Westrich GH. Ceramic-on-ceramic total hip arthroplasty.Incidence of instability and noise. Clin Orthop Relat Res2011;469:437—42.

22] Glaser D, Komistek RD, Cates HE, Mahfouz MR. Clicking andsqueaking: in vivo correlation of sound and separation for dif-ferent bearing surfaces. J Bone Joint Surg Am 2008;90:112—20.

23] Chevillotte C, Pibarot V, Carret JP, Bejui-Hugues J, GuyenO. Nine years follow-up of 100 ceramic-on-ceramic total hiparthroplasty. Int Orthop 2010;35:1599—604.

24] Traina F, De Fine M, Bordini B, Toni A. Risk factors forceramic liner fracture after total hip arthroplasty. Hip Int

2012;22:607—14.

25] Nordt W, Giangarra CE, Levy IM, Habermann ET. Arthroscopicremoval of entrapped debris following dislocation of a total hiparthroplasty. Arthroscopy 1987;3:196—8.